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Utilizing a cognitive engineering approach to conduct a hierarchical task analysis to understand complex older adult decision-making during over-the-counter medication selection
Abstract
Background
Adults aged 65+ (older adults) disproportionately consume 30% of over-the-counter (OTC) medications and are largely responsible for making OTC treatment decisions because providers lack awareness of their consumption. These treatment decisions are complex: older adults must navigate age-related body/cognitive changes, developed comorbidities, and complex medication regimens when selecting the right OTC. Yet little is known about how older adults make such decisions.
Objectives
This study characterizes older adults' cognitive decision-making process when seeking to self-medicate with OTCs from their community pharmacy, and demonstrates how hierarchical task analysis (HTA) can be used to evaluate a pharmacy intervention's impact on their decision-making.
Methods
A pre-/post-implementation approach, using a think-aloud interview process, was conducted with older adults within a community pharmacy setting as they completed a hypothetical scenario to treat either pain, sleep, or cough/cold/allergy symptoms. HTA developed a conceptualization of older adult decision-making regarding OTC selection and use before/after Senior Section implementation.
Results
An HTA constructed from 12 purposefully-selected interviews (pre-n = 9/post-n = 3), consisting of 8 goals/15 sub-goals. While selecting an OTC, older adults considered quantity, cost, form, regimen, safety, strength, appropriateness of OTC safety, generic/name-brand, past experiences, and ingredients. The intervention reduced by half the number of factors considered.
Implications
Older adult decision-making is more complex than just selecting OTC medication from a pharmacy shelf. HTA-informed decision profiles can provide pharmacists critical insights into safety issues that older adults may not be considering (e.g., factors related to safety, strength, or appropriateness of OTC for symptoms) so that pharmacists can support their decision-making.
Cognitive Task Analysis (CTA) is a powerful methodological approach that can enhance the rigorous elicitation and documentation of complex cognitive processes within interview-based qualitative research. We provide insights into this set of semi-structured interviewing techniques that we contend have much to offer management researchers who wish to understand the complexities of expert cognition within specific work-related tasks. Distinct from traditional semi-structured interview methods, CTA is designed to identify the knowledge requirements underpinning expertise in complex work domains. First, we present CTA as a robust approach to eliciting complex cognition and note why, when, and where management scholars might best use its techniques. Second, we provide two examples of how CTA methods have been used to research management; specifically, using the Critical Decision Method to explore management in high-stakes environments, and Applied Cognitive Task Analysis to explore global leadership. In ending, we propose greater use of this pragmatic approach in management research and highlight potential avenues for future research that will advance understanding of complex cognition at work.
Objectives
Older adults’ (ages ≥65) inappropriate over-the-counter medications (OTC) use is prevalent, comprising Drug-Age, Drug-Drug, Drug-Disease, and Drug-Label types. Given that pharmacies sell many OTCs, structurally redesigning pharmacy aisles for improving patient safety (Senior Safe) was conceived to mitigate older adult OTC misuse, using Stop Signs and Behind-the-Counter Signs for high-risk OTCs. This study determined whether Senior Safe reduced high-risk OTCs misuse, while secondarily evaluating misuse changes for all OTCs.
Methods
A randomized controlled trial design matched and randomly allocated 20 health system community pharmacies to control or intervention groups. All 288 study participants completed an OTC choice task in which they chose a hypothetical symptom scenario (pain, sleep, cough/cold/allergy), selected an OTC, and described how they would use it at symptom onset and if symptoms persisted or worsened. Reported OTC use was evaluated for each misuse type. Intervention and control sites were compared for each misuse type using multivariate modeling.
Results
For high-risk OTCs, Drug-Age and Drug-Drug misuse were more likely in control sites (OR = 2.752, P = 0.004; OR = 6.199, P = 0.003, respectively), whereas Drug-Disease and Drug-Label misuse had too few occurrences in intervention sites for statistical comparisons. For all OTCs, only Drug-Age misuse was more likely for control sites (OR = 5.120, P = 0.001). Adults aged 85+ years had the greatest likelihood of all misuse types.
Conclusions
Results demonstrated that older adults frequently reported multiple misuse types, highlighting safety concerns. Senior Safe reduced high-risk OTC misuse, especially for older adults younger than 85 years. Cumulatively, these findings provide insights into practice recommendations supported through regulatory guidance.
Introduction: The increase of people with complex chronic health conditions is stressing the U.S. healthcare delivery system. Community pharmacies play a role in ensuring patients’ safe medication use for chronic care management, but their efforts are undermined by volatile work demands and other system barriers.
Methods: This study seeks to conceptualize, design, implement, and test a MedSafeMapTM for the community pharmacy setting to enhance pharmacists’ and technicians’ abilities to either avoid, or to quickly identify and recover from, medication errors before patient safety is endangered.
Discussion: The MedSafeMap is an innovative approach that will be used by pharmacists and pharmacy technicians to better navigate the complex tasks in the pharmacy, and to facilitate communication with both patients and clinicians, while safely providing medications to complex patients with chronic health conditions.
Over-the-counter (OTC) medications are products that have been made easily accessible to allow patients to treat common ailments without a prescription and the cost of a doctor’s visit. These medications are generally considered safe; however, there is still a potential for these medications to lead to adverse health outcomes. Older adults (ages 50+) are especially susceptible to these adverse health outcomes, due to age-related physiological changes, a higher prevalence of comorbidities, and prescription medication use. Many OTC medications are sold in pharmacies, which provides pharmacists and technicians with the opportunity to help guide safe selection and use for these medications. Therefore, community pharmacies are the ideal setting for OTC medication safety interventions. This narrative review summarizes the findings of pharmacy-involved interventions that promote safe OTC medication use for older adults.
Background:
Designing clinical decision support (CDS) tools is challenging because clinical decision-making must account for an invisible task load: incorporating non-linear objective and subjective factors to make an assessment and treatment plan. This calls for a cognitive task analysis approach.
Objectives:
The objectives of this study were to 1.) understand healthcare providers' decision making during a typical clinic visit, and 2.) explore how antibiotic treatment decisions are made when they arise.
Methods:
Two cognitive task analysis methods were applied - Hierarchical Task Analysis (HTA) and Operations Sequence Diagramming (OSD) - to 39 h of observational data collected at family medicine, urgent care, and emergency medicine clinical sites.
Results:
The resulting HTA models included a coding taxonomy detailing ten cognitive goals and associated sub-goals and demonstrated how the goals occur as interactions between the provider and electronic health record, the patient, and the physical clinic environment. Although the HTA detailed resources for antibiotic treatment decisions, antibiotics were a minority of drug classes ordered. The OSD shows the sequence of events and when decisions are made solely at the provider level and when shared decision making occurs with the patient. Qualitative data from the observations informed a constructed vignette case example portraying select tasks from the HTA.
Conclusions:
These findings emphasize that the scope of disease states presenting to a generalist clinical setting is broad and could include acute exacerbations of rare diseases within a time-pressured environment. CDS must be accessible, time efficient, and fit within the resource gathering task before treatment decisions are made.
Safe over the counter (OTC) medication use by older adults (OAs, aged 65+) is difficult to achieve because of age-related physiologic complexities, and millions of OAs in the US who are at risk of experiencing a major adverse drug event linked to an OTC medication. Our interdisciplinary team studies how we can improve OTC safety in OAs by developing human factors-based, community pharmacy interventions. Testing the effectiveness of our interventions on improving OTC safety necessitated the development of a framework that captures the ways OTC medication misuse can occur and designing and implementing a tool that can be used to evaluate for potential misuse, which can be used by researchers and healthcare professionals to understand misuse in OAs. This paper shares the results of our efforts and discusses the implications of our work for other HF practitioners that may be interested applying our approach to their research.
Introduction:
The Senior Section is a continuation of a previous intervention that aims to address a gap in medication safety, specifically related to older adult selection and use of over-the-counter medications. The purpose of this paper is to describe the protocol of this study.
Methods:
This study will occur in three phases: an adaptation phase, an effectiveness phase using a randomized controlled trial, and a sustainment phase. This study will take place in conjunction with administrative leadership and pharmacy sites of a regional Midwest integrated health system. Eye tracking technology will inform the adaptation of the intervention and demonstrate effectiveness in the randomized controlled trial. Following the randomized controlled trial, the health system will implement the intervention without research team support. Fidelity and long-term effectiveness outcomes will be collected to demonstrate sustainment.
Discussion:
The potential implications of this study are a complete and sustained redesign of the pharmacy setting to include educational and directional materials on medication safety, leading to a decrease in over-the-counter medication misuse in older adults. This project could provide a road map for pharmacy organizations to tailor and adopt the Senior Section, to ultimately reduce inappropriate over-the-counter medication use in older adults.
Background The unintentional misuse of over-the-counter sleep aids among older adults is an important public health problem and a focus of Healthy People 2020. Accordingly, the 2015 Beers Criteria for Potentially Inappropriate Medication Use in Older Adults recommends that individuals 65 years or older avoid use of diphenhydramine and doxylamine; however, many over-the-counter sleep products contain these active ingredients. Objective To identify the proportion of older adults using an over-the-counter medication containing diphenhydramine or doxylamine, and compare their characteristics with older adults using an over-the-counter medication that does not contain these ingredients. Setting Study participants were recruited from the Community Registry of the Pittsburgh Claude D. Pepper Older Americans Independence Center. Method The study sample was taken from a larger survey of 1025 participants on sleep health and over-the-counter sleep medication use conducted from February to April 2015. A subset of 169 participants aged 65 and older reporting taking at least one over-the-counter product to improve sleep within the past 30 days (16.5%) were selected for our analysis on associations between participant characteristics and potentially inappropriate use of over-the-counter sleep medications. Main outcome measure The proportion and characteristics of older adults taking at least one over-the-counter medication containing diphenhydramine or doxylamine. Results Of the 223 over-the-counter sleep medications listed by participants, 115 (52%) contained diphenhydramine or doxylamine. Using the Beers Criteria, we found that more than half of participants (59%) had used a potentially inappropriate over-the-counter medication containing diphenhydramine or doxylamine to improve sleep within the past 30 days. Participants taking at least one diphenhydramine or doxylamine containing medication were less likely to be aware of any safety risks in taking over-the-counter sleep medications than participants not taking these products (38 vs 49%, p = 0.016). Conclusion A majority of older adults in a limited sample from the United States taking an over-the-counter medication to improve sleep are taking a product containing diphenhydramine or doxylamine, both of which are classified as potentially inappropriate for older adults. Awareness of the safety risks of over-the-counter medications and addressing conditions that impact sleep quality could be facilitated through consultation with pharmacists and other healthcare providers.
Electronic supplementary material
The online version of this article (doi:10.1007/s11096-017-0467-x) contains supplementary material, which is available to authorized users.
Cognitive Task Analysis (CTA) has become part of the standard tool set of cognitive engineering. CTAs are routinely used to understand the cognitive and collaborative demands that contribute to performance problems, the basis of expertise, as well as the opportunities to improve performance through new forms of training, user interfaces, or decision aids. While the need to conduct CTAs has become well established, there is little in the way of available guidance with respect to ‘best practice’ for how to conduct a CTA or how to evaluate the quality of a CTA that has been conducted by others. This is an important gap as the range of consumers of CTAs is expanding to include program managers and regulators who may need to make decisions based on CTA findings. This panel brings together some of the leaders in development and application of CTA methods to address the question: Given the variety of methods available, and the lack of rigid guidance on how to perform a CTA, how does one judge the quality of a CTA?” The goal of the panel is to explore points of consensus with respect to ‘best practice’ in conducting and evaluating a CTA, in spite of differences in particular CTA methods, as well as to draw insights from unique and provocative perspectives.
Healthcare practitioners, patient safety leaders, educators and researchers increasingly recognise the value of human factors/ergonomics and make use of the discipline's person-centred models of sociotechnical systems. This paper first reviews one of the most widely used healthcare human factors systems models, the Systems Engineering Initiative for Patient Safety (SEIPS) model, and then introduces an extended model, 'SEIPS 2.0'. SEIPS 2.0 incorporates three novel concepts into the original model: configuration, engagement and adaptation. The concept of configuration highlights the dynamic, hierarchical and interactive properties of sociotechnical systems, making it possible to depict how health-related performance is shaped at 'a moment in time'. Engagement conveys that various individuals and teams can perform health-related activities separately and collaboratively. Engaged individuals often include patients, family caregivers and other non-professionals. Adaptation is introduced as a feedback mechanism that explains how dynamic systems evolve in planned and unplanned ways. Key implications and future directions for human factors research in healthcare are discussed.
Technical communicators have lately become interested in participatory design as a way to structure and guide their research and development efforts, particularly in online media. But attempts to use participatory design - in technical communication and elsewhere - have been hampered because participatory design has typically been seen as an orientation or field rather than a methodology with its own methods, techniques, and acceptable range of research designs. In this article, I work with a range of participatory design sources to describe it as a methodology useful for technical communicators. After providing the historical and methodological grounding for understanding participatory design as a methodology, I describe its research designs, methods, criteria, and limitations. Finally, I provide guidance for applying it to technical communication research.
Self-medication is defined as the selection and use of medicines by individuals (or a member of the individuals' family) to treat self-recognized or self-diagnosed conditions or symptoms. Several benefits have been linked to appropriate self-medication, among them: increased access to medication and relief for the patient, the active role of the patient in his or her own health care, better use of physicians and pharmacists skills and reduced (or at least optimized) burden of governments due to health expenditure linked to the treatment of minor health conditions However, self-medication is far from being a completely safe practice, in particular in the case of non-responsible self-medication. Potential risks of self-medication practices include: incorrect self-diagnosis, delays in seeking medical advice when needed, infrequent but severe adverse reactions, dangerous drug interactions, incorrect manner of administration, incorrect dosage, incorrect choice of therapy, masking of a severe disease and risk of dependence and abuse. In this short review the author analyzes recent literature on some of the most important dangers related to self-medication practices, particularly: polypharmacy and drug interactions, medications abuse or dependence, misdiagnosis and incorrect choice of treatment. The author also proposes measures that could be adopted in order to solve or improve these issues.
To describe physicians' patterns of using an Electronic Medical Record (EMR) system; to reveal the underlying cognitive elements involved in EMR use, possible resulting errors, and influences on patient-doctor communication; to gain insight into the role of expertise in incorporating EMRs into clinical practice in general and communicative behavior in particular.
Cognitive task analysis using semi-structured interviews and field observations.
Twenty-five primary care physicians from the northern district of the largest health maintenance organization (HMO) in Israel.
The comprehensiveness, organization, and readability of data in the EMR system reduced physicians' need to recall information from memory and the difficulty of reading handwriting. Physicians perceived EMR use as reducing the cognitive load associated with clinical tasks. Automaticity of EMR use contributed to efficiency, but sometimes resulted in errors, such as the selection of incorrect medication or the input of data into the wrong patient's chart. EMR use interfered with patient-doctor communication. The main strategy for overcoming this problem involved separating EMR use from time spent communicating with patients. Computer mastery and enhanced physicians' communication skills also helped.
There is a fine balance between the benefits and risks of EMR use. Automaticity, especially in combination with interruptions, emerged as the main cognitive factor contributing to errors. EMR use had a negative influence on communication, a problem that can be partially addressed by improving the spatial organization of physicians' offices and by enhancing physicians' computer and communication skills.
The purpose of this study was to describe physician-patient communication about over-the-counter medications using a data set comprised of audio-tapes and transcripts of 414 primary care medical visits. The data set was collected during 1995 at the family practice and general medicine clinics at the University of New Mexico Health Sciences Center. Twenty-seven resident physicians and 414 of their adult patients participated. Fifty-seven percent of patients reported using one or more OTC medications during the past month. Analgesics, cold or allergy products, and antacids were the most commonly used OTC medications. White patients were significantly more likely to have reported using an analgesic in the past month than non-white patients. Female, white, and younger patients were more likely to have reported using a cold or allergy product in the past month than male, non-white, and older patients. Approximately 58% of patients discussed OTC medications with their physicians. Older patients and female patients as well as patients who reported using an antacid in the past month were significantly more likely to have discussed OTC medications with their physicians. Physicians asked questions about OTC medications during only 37% of encounters. Patients asked questions about OTC medications during 11% of encounters. Patient ethnicity did not influence physician or patient question-asking and information-giving about OTC medications. Male physicians were more likely to state information and ask questions about OTC medications than female physicians. Patients were more likely to ask male physicians questions about OTC medications. Physicians were more likely to state OTC information to and ask OTC questions of female and older patients. Physicians were more likely to ask less educated patients questions about OTC medications. Less educated patients were more likely to ask physicians questions about OTC medications. Despite the fact that more than half of all patients reported using OTC medications, physicians asked questions about OTC use during only approximately one-third of encounters. Of patients who reported using an OTC medication in the past month, 58% did not tell their physicians, yet only 14% of patients believed that it was not important for the physician to know about their OTC use. Physician-patient communication about OTC medications should be encouraged so that the patient becomes a collaborative partner in medication management.
Hierarchical task analysis (HTA) is a core ergonomics approach with a pedigree of over 30 years continuous use. At its heart, HTA is based upon a theory of performance and has only three governing principles. Originally developed as a means of determining training requirements, there was no way the initial pioneers of HTA could have foreseen the extent of its success. HTA has endured as a way of representing a system sub-goal hierarchy for extended analysis. It has been used for a range of applications, including interface design and evaluation, allocation of function, job aid design, error prediction, and workload assessment. Ergonomists are still developing new ways of using HTA which has assured the continued use of the approach for the foreseeable future.
To assess the relationship between decision making and successful diabetes self-management.
Patients with type II diabetes make routine but critical self-management decisions.
We conducted cognitive task analysis interviews with 18 patients to examine problem detection, functional relationships, problem-solving strategies, and types of knowledge used to make self-management decisions. We expected that these decision processes would be related to behavioral adherence and glycemic control.
Verbal reports displaying problem detection skills, knowledge of functional relationships, and effective problem-solving strategies were all related to better adherence. Problem detection skill was linked to greater glycemic control. Participants differed in declarative and applied knowledge.
Diabetes self-management draws on the same cognitive skills found in experts from diverse professional domains. Considering diabetes self-management as a form of expertise may support adherence.
Human factors approaches that support professional expertise may be useful for the decision making of patients with diabetes and other chronic diseases.
Personas can be used to understand patterns of variation in patients’ performance of cognitive work, particularly self-care decision making. In this study, we used a patient-centered cognitive task analysis (P-CTA) to develop self-care decision-making personas. We collected data from 24 older adults with chronic heart failure and 14 support persons, using critical incident and fictitious scenario interviews. Qualitative analyses produced three personas but revealed that individuals exemplify different personas across situations. The Rule-Following persona seeks clear rules, exercises caution under uncertainty, and grounds actions in confidence in clinician experts. The Researching persona seeks information to gain better understanding, invents strategies, and conducts experiments independently or with clinicians. The Disengaging persona does not actively seek rules or information and does not attempt to reduce uncertainty or conduct experiments. We discuss the situational nature of personas, their use in design, and the benefits of P-CTA for studying patient decision making.
The Systems Engineering Initiative for Patient Safety (SEIPS) and SEIPS 2.0 models provide a framework for integrating Human Factors and Ergonomics (HFE) in health care quality and patient safety improvement. As care becomes increasingly distributed over space and time, the “process” component of the SEIPS model needs to evolve and represent this additional complexity. In this paper, we review different ways that the process component of the SEIPS models have been described and applied. We then propose the SEIPS 3.0 model, which expands the process component, using the concept of the patient journey to describe the spatio-temporal distribution of patients’ interactions with multiple care settings over time. This new SEIPS 3.0 sociotechnical systems approach to the patient journey and patient safety poses several conceptual and methodological challenges to HFE researchers and professionals, including the need to consider multiple perspectives, issues with genuine participation, and HFE work at the boundaries.
Patient ergonomics is the application of human factors or related disciplines to study and improve patients' and other non-professionals' performance of effortful work activities in pursuit of health goals. We performed a mapping review of 212 full-text patient ergonomics publications in two conference proceedings, 2007-2017. The review revealed a robust and growing body of literature on patient ergonomics, particularly in the areas of aging and chronic disease, tools and technologies, and evaluations of patient-centered interventions on outcomes such as usability, user acceptance, and performance. Findings highlighted gaps deserving future research, including research with understudied populations such as children, informal caregivers, networks and collectives (groups), and marginalized populations; on topics such as health promotion and transitions of care; and using longitudinal and experimental study designs. The growth of patient-centeredness in general and of patient ergonomics in particular compel other more focused reviews, new primary research, and developing a roadmap for future patient ergonomics research.
Background and objective:
Self-medication is associated with an important utilization of Over-The-Counter (OTC) analgesics. The medical outcome resulting from therapeutic options bypassing the physician prescription is a major issue. In that context, pharmacists are expected to play a crucial role. The main objective of this review was to analyse the state-of-the art of pharmacists' role in pain management self-medication DATABASES AND DATA TREATMENT: An expert multidisciplinary group dedicated to self-medication in pain was established. Selection of publications was performed from PubMedand EMBASE databases which was based on the use of 'pain' and/or 'self-medication' and/or 'selfcare' and/or 'analgesics' and/or 'painkillers' keywords, restricted to the past 10-years.
Results:
A total of 480 papers were identified, 49 of which papers were considered relevant and finally kept for final discussion, on OTC pain management and pharmacist's role. Literature analysis demonstrates that OTC analgesics are generally safe when appropriately used. Risks associated with misuse or inappropriateness depend on patients' vulnerability (elderly, pregnancy) or behaviour. Social cognitive theory-based intervention and multimedia applications improve self-medication but do not replace healthcare professional advice Pharmacists' interventions may improve the benefits and safety of OTC analgesic medication, with a better management of pain.
Conclusions:
Considering the heterogeneity of patients' knowledge and behaviour reported worldwide, inappropriate use of OTC pain medication should not be underestimated. Community pharmacists are ideally placed to guide self-medication or recommend a medical advice when needed. Embedding pharmacists in primary care pain management is essential and pharmacist-led medication coupled with an appropriate training of pharmacy staffs should be encouraged. This article is protected by copyright. All rights reserved.
Objectives
To study the effect of caregiver‐focused interventions to support medication safety in older adults with chronic disease.
Design
Systematic review.
Setting
Studies published before January 31, 2017, searched using Ovid Medline, PubMed, EMBASE, Scopus, CINAHL, PsycINFO, and Google Scholar.
Participants
Caregivers with or without a care recipient.
Measurements
Inclusion criteria: interventions focused on caregivers aiming to improve medication safety. Studies not focusing on older adults, not evaluating medication safety, failing to include caregivers, or without a comparison group were excluded.
Results
The initial search revealed 1,311 titles. Eight studies met inclusion criteria. The strategies used in randomized trials were a home‐based medication review and adherence assessment by a clinical pharmacist (2 home visits 6–8 weeks apart, with pharmacist and physician meeting independently) that found no difference in nonelective hospital admissions (p=.8) but fewer medications (p=.03); a 19‐minute educational DVD and an hour‐long medication education and training that improved caregiver satisfaction (p<.04); a medication education and adherence intervention (2–3 home visits per care recipient and caregiver dyad over 8 weeks) that found no difference in knowledge, administration, or accessibility of medications (p=.29); and a collaborative case management program (16‐month program of assessment, meeting, and monthly follow‐up telephone calls) that reduced perceived caregiver burden (p=.03). Quasi‐experimental trials included collaborative care transitional coaches, an outpatient collaborative care model, and education and training programs. Of these, educational interventions showed improvements in self‐efficacy, confidence, and preparedness. The collaborative care intervention reduced rehospitalizations (p=.04) and improved quality‐of‐care outcomes.
Conclusion
Although some interventions improved caregiver medication knowledge and self‐efficacy, effects on clinical outcomes and healthcare use were insufficiently studied. Two studies implementing collaborative care models with medication management components showed potential for improvement in quality of clinical care and reductions in healthcare visits and warrant further study with respect to medication safety.
Background: Older adults with low health literacy are at increased risk of nonadherence, accidental drug exposure, and adverse events. Purpose: This study evaluated older adults’ knowledge and awareness of medication safety and poison prevention resources using an interactive educational game compared to a less intensive intervention involving individual review of brochures. Methods: Both groups were given pre- and postintervention surveys to assess change in knowledge. Participants were followed up at 30 days to assess knowledge retention and behavior changes. Results: A total of 101 older adults participated in the study. In the game group, the median improvement in the index score pre- and postintervention was 3, moving from 9 (interquartile range [IQR] 6, 9) to 11 (IQR 9, 12). The brochure group median improvement was 1, moving from 7.5 (IQR 6, 8) to 8 (IQR 5, 10). Comparing postintervention to 30-day follow-up, over 50% of respondents retained the correct responses. Discussion: The interactive game significantly improved knowledge regarding use of child-resistant cap, interpreting a drug facts label, medication list documentation, and who to call for advice. Translation to Health Education Practice: This educational intervention has potential to increase awareness of poison prevention resources and medication safety strategies in older adults with low health literacy.
Purpose:
Older adults are at increased risk of adverse drug events due to medication. Older adults tend to take more medication and are at higher risk of chronic illness. Over-the-counter (OTC) medication does not require healthcare provider oversight and understanding OTC information is heavily dependent on a consumer's ability to understand and use the medication appropriately. Coupling health technology with effective communication is one approach to address the challenge of communicating health and improving health related tasks. However, the success of many health technologies also depends on how well the technology is designed and how well it addresses users needs. This is especially true for the older adult population. This paper describes (1) a formative study performed to understand how to design novel health technology to assist older adults with OTC medication information, and (2) how a user-centered design process helped to refine the initial assumptions of user needs and help to conceptualize the technology.
Methods:
An iterative design process was used. The process included two brainstorming and review sessions with human-computer interaction researchers and design sessions with older adults in the form of semi-structured interviews. Methods and principles of user-centered research and design were used to inform the research design. Two researchers with expertise in human-computer interaction performed expert reviews of early system prototypes. After initial prototypes were developed, seven older adults were engaged in semi-structured interviews to understand usability concerns and features and functionality older adults may find useful for selecting appropriate OTC medication.
Results:
Eight usability concerns were discovered and addressed in the two rounds of expert review, and nine additional usability concerns were discovered in design sessions with older adults. Five themes emerged from the interview transcripts as recommendations for design. These recommendations represent opportunities for technology such as the one described in this paper to support older adults in the OTC decision-making process.
Discussion:
This paper illustrates the use of an iterative user-centered process in the formative stages of design and its usefulness for understanding aspects of the technology design that are useful to older adults when making decisions about OTC medication. The technology support mechanisms included in the initial model were revised based on the results from the iterative design sessions and helped to refine and conceptualize the system being designed.
The use of analgesics increases with age and on any given day 20–30% of older adults take an analgesic medication. Over-the-counter (OTC) analgesics are generally well tolerated and effective when taken for brief periods of time and at recommended dosages. However, their long-term use, use at inappropriately high doses, or use by persons with contraindications may result in adverse effects, including gastrointestinal haemorrhage, cardiovascular toxicity, renal toxicity and hepatotoxicity. Many OTC drugs are also available through a prescription, for a broader range of indications and for longer durations of use and wider dose ranges, under the assumption that healthcare providers will help patients make safe choices about analgesics. Safe and effective use of medications is one of the greatest challenges faced by healthcare providers in medicine. More than 60% of people cannot identify the active ingredient in their brand of pain reliever. Additionally, about 40% of Americans believe that OTC drugs are too weak to cause any real harm. As a result of a recent US FDA policy, the conversion of prescription to OTC medications will result in a 50% increase of OTC medications. To reduce the risks of potential adverse effects from OTC drug therapy in older adults, we propose that the use of analgesics will be enhanced through the use of patient and healthcare provider education, as well as improved labelling of OTC analgesics. Improved labelling of OTC analgesics may help consumers distinguish common analgesic ingredients in a wide variety of preparations and facilitate informed decisions concerning the use of OTC drugs.
Warning comprehension is critical to safely use medications and products with health-related consequences, especially for older adults who often use multiple medications. The ability to infer from short texts influences the warning comprehension process and in turn is influenced by prior knowledge. Mixed evidence suggests that age may moderate inferencing ability. This study combined quantitative and qualitative measures to explore the role of prior knowledge in inferencing and age-related differences in the nature of the information used. Twenty younger (18–28) and 20 older (65–75) adults evaluated whether 16 one-sentence statements were true (consistent) or false (inconsistent) in relation to two-sentence text passages that were real (i.e. taken from products such as cleaners and OTC medications) or their reverse. Statements contained information explicitly stated or implied in the text passage. Accuracy was generally high, higher for real text passages (than reversed) and explicit statements (than implicit). Older adults did less well than younger adults for reversed text passages. Qualitative analyses suggest that given contradictory information, older adults rely on prior knowledge more than younger adults, which may account for age-related differences in their conclusions. Thus, older adults may be more likely to misinterpret health-related communications if the information conflicts with their prior knowledge.
The number of over-the-counter (OTC) medications is increasing as more prescription medications are being switched to OTC status. Many older adults rely on self-management of medications to treat common medical conditions such as the common cold, pain, diarrhea, and constipation. Although OTC medications are regulated by the U.S. Food and Drug Administration and Health Canada, many people are unaware of proper dosing, side effects, adverse drug reactions, and possible medication interactions that may not be clearly labelled. This article reviews the major side effects of common OTC medications and how to recognize these adverse effects, and provides health care professionals with information to offer to older adults and their caregivers about safe OTC medication use.
Surrogate decision makers (SDMs) face difficult decisions at end of life (EOL) for decisionally incapacitated intensive care unit (ICU) patients.
To identify and describe the underlying psychological processes of surrogate decision making for adults at EOL in the ICU.
Qualitative case study design using a cognitive task analysis interviewing approach. Participants were recruited from October 2012 to June 2013 from an academic tertiary medical center's ICU located in the rural Northeastern United States. Nineteen SDMs for patients who had died in the ICU completed in-depth semistructured cognitive task analysis interviews.
The conceptual framework formulated from data analysis reveals that three underlying, iterative, psychological dimensions (gist impressions, distressing emotions, and moral intuitions) impact an SDM's judgment about the acceptability of either the patient's medical treatments or his or her condition.
The framework offers initial insights about the underlying psychological processes of surrogate decision making and may facilitate enhanced decision support for SDMs.
Copyright © 2015 Elsevier Inc. All rights reserved.
Research on the ways older people use prescription medications (Rx) is a mainstay of the gerontological literature because use of Rx medications is common, and appropriate use is central to effective management of chronic disease. But older adults are also major consumers of over-the-counter (OTC) medications, which can be equally significant for self-care. Nearly half of older adults aged 75-85, for example, are regular users of an OTC product. Ensuring that consumers safely and effectively use OTC products is critical in order to minimize potential drug-drug interactions and unintentional misuse. Yet we know surprisingly little about the ways older adults select OTC medications and decide when to start or stop use, how older people actually take these medications, or how involved clinicians and family members are in older adult OTC behavior. Research in this area is critical for developing interventions to help ensure safe and appropriate OTC use. For this reason, The Gerontological Society of America (GSA), in partnership with the Consumer Healthcare Products Association (CHPA), convened a summit of experts to set an agenda for research in OTC behaviors among older adults. The panel suggested a need for research in 5 key areas: Health literacy and OTC behavior, decision making and OTC use, the role of clinicians in OTC medication behavior, older adult OTC behavior and family care, and technologies to promote optimal use of OTC medications.
Understanding the needs of various stakeholders throughout the design process is key for creating consumer health applications that are usable, effective, and useful for the people that use them. This paper discusses the findings of an exploratory study aimed at understanding the current practices, information needs, and challenges of older adults (65 years and older) when selecting over-the-counter (OTC) medication. The context of this study lies in understanding older adults with the purpose of identifying opportunities for a consumer health application to assist them with selecting an appropriate OTC medication based on their health history. This research contributes to the understanding of the current practices of older adults as related to OTC medication selection. In addition, this paper provides a discussion of opportunities for future applications to help facilitate this task for older adults.
Cognitive task analysis (CTA) is enjoying growing popularity in both research and practice as a foundational element of instructional design. However, there exists relatively little research exploring its value as a foundation for training through controlled studies. Furthermore, highly individualized approaches to conducting CTA do not permit broadly generalizable conclusions to be drawn from the findings of individual studies. Thus, examining the magnitude of observed effects across studies from various domains and CTA practitioners is essential for assessing replicable effects. This study reports the findings from a meta-analysis that examines the overall effectiveness of CTA across practitioners and settings in relation to other means for identifying and representing instructional content. Overall, the effect of CTA-based instruction is large (Hedges's g = 0.871). However, effect sizes vary substantially by both CTA method used and training context. Though limited by a relatively small number of studies, the notable effect size indicates that the information elicited through CTA provides a strong basis for highly effective instruction.
The efficacy of prescription medications depends on user compliance. Compliance on the other hand depends on understanding. This paper describes three studies of medication instructions. The cognitive psychology lietature about physical features, language, and organization is tapped to guide the revision of standard medication instructions. Furthermore, the redesigned instruction is compared with conventional instructions among samples of college students, older adults, and pharmacy outcomes.
This study proposes methods for blending design components of clinical effectiveness and implementation research. Such blending can provide benefits over pursuing these lines of research independently; for example, more rapid translational gains, more effective implementation strategies, and more useful information for decision makers. This study proposes a "hybrid effectiveness-implementation" typology, describes a rationale for their use, outlines the design decisions that must be faced, and provides several real-world examples.
An effectiveness-implementation hybrid design is one that takes a dual focus a priori in assessing clinical effectiveness and implementation. We propose 3 hybrid types: (1) testing effects of a clinical intervention on relevant outcomes while observing and gathering information on implementation; (2) dual testing of clinical and implementation interventions/strategies; and (3) testing of an implementation strategy while observing and gathering information on the clinical intervention's impact on relevant outcomes.
The hybrid typology proposed herein must be considered a construct still in evolution. Although traditional clinical effectiveness and implementation trials are likely to remain the most common approach to moving a clinical intervention through from efficacy research to public health impact, judicious use of the proposed hybrid designs could speed the translation of research findings into routine practice.
To describe the different methods that older adults use to treat sleep problems and the perceived effectiveness of these methods.
Cross-sectional study of treatment patterns for sleep disorders using a mailed questionnaire that gathered information concerning sleep history, demographics, and treatment choices.
Community.
Community-based sample of adults aged 65 and older, of whom 242 responded (67% response rate).
Standardized questionnaires to assess sleep parameters (Pittsburgh Sleep Quality Index), demographic information, and sleep treatment options.
Study participants engaged in a variety of treatment regimens to improve their sleep, with the average number of treatments attempted being 4.8±2.9. The most commonly used interventions were watching television or listening to the radio (66.4%) and reading (56.2%). The most commonly used pharmacotherapy was pain medication (40.1%). Prescription sleeping pills had the greatest self-reported effectiveness. Approximately half of all study participants who used alcohol or over-the-counter sleep aids had not discussed their sleep problems with their doctor.
Older adults frequently choose treatments for their sleep problems that can potentially worsen their sleep symptoms. Many patients have not spoken to their healthcare provider about their treatment choices. These findings highlight the importance of discussing sleep habits and self-treatment choices, as well as treating sleep disorders, in older adults.
Severe acetaminophen hepatotoxicity frequently leads to acute liver failure (ALF). We determined the incidence, risk factors, and outcomes of acetaminophen-induced ALF at 22 tertiary care centers in the United States. Detailed prospective data were gathered on 662 consecutive patients over a 6-year period fulfilling standard criteria for ALF (coagulopathy and encephalopathy), from which 275 (42%) were determined to result from acetaminophen liver injury. The annual percentage of acetaminophen-related ALF rose during the study from 28% in 1998 to 51% in 2003. Median dose ingested was 24 g (equivalent to 48 extra-strength tablets). Unintentional overdoses accounted for 131 (48%) cases, intentional (suicide attempts) 122 (44%), and 22 (8%) were of unknown intent. In the unintentional group, 38% took two or more acetaminophen preparations simultaneously, and 63% used narcotic-containing compounds. Eighty-one percent of unintentional patients reported taking acetaminophen and/or other analgesics for acute or chronic pain syndromes. Overall, 178 subjects (65%) survived, 74 (27%) died without transplantation, and 23 subjects (8%) underwent liver transplantation; 71% were alive at 3 weeks. Transplant-free survival rate and rate of liver transplantation were similar between intentional and unintentional groups. In conclusion, acetaminophen hepatotoxicity far exceeds other causes of acute liver failure in the United States. Susceptible patients have concomitant depression, chronic pain, alcohol or narcotic use, and/or take several preparations simultaneously. Education of patients, physicians, and pharmacies to limit high-risk use settings is recommended.
Use of over-the-counter (OTC) medications is becoming more of a problem in the older adult population as the push to deregulate prescription medications grows. This article summarizes the side effects, adverse reactions, and medication interactions older adults face when using some common OTC medications.
A critical decision method is described for modeling tasks in
naturalistic environments characterized by high time pressure, high
information content, and changing conditions. The method is a variant of
a J.C. Flanagan's (1954) critical incident technique extended to include
probes that elicit aspects of expertise such as the basis for making
perceptual discriminations, conceptual discriminations, typicality
judgments, and critical cues. The method has been used to elicit domain
knowledge from experienced personnel such as urban and wildland
fireground commanders, tank platoon leaders, structural engineers,
design engineers, paramedics, and computer programmers. A model of
decision-making derived from these investigations is presented as the
theoretical background to the methodology. Instruments and procedures
for implementing the approach are described. Applications of the method
include developing expert systems, evaluating expert systems'
performance, identifying training requirements, and investigating basic
decision research issues
American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 updated beers criteria for potentially inappropriate medication use in older adults
- Fick
Consumer decision making
- Bettman
Effectiveness-implementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact
- Curran
Comparing apples with apples: hierarchical task analysis as a simple systems framework to improve patient safety
- Hignett